Please help me. I know you are all busy, but my last two questions went unanswered and I am still a bit in the wilderness. I now need to make a decision and dont want to hold off for any longer.

Okay, here are the facts: 1. Have been living with the HIV virus for 15 years. 2. Am still not on medications 3. VL is 9000 and T4s are 270. 4. On heavy-duty natural regime.

5. Now the BIG question: It is time for me to start medications. My doc has suggested a combo of * AZT * Nevarpine * ddI.

However, the HIV expert professor from the local university instead recommends: *Hydroxyurea *ddI

A third opinion agrees with my doc and not the professor. What do you think? I am very lost here.

Thanks for all your help, Gus

Hey gus -

Well, first off. It is reasonable to start, given that I can assume your CD4 count has been slowly dropping and that drop inspires your decision?

The "good" news in your story is the low viral load of only 9000. That means that essentially every regimen we use would work, as they are all amply potent. Your advisors however are coming from two different schools of thought about the best next steps, and since we are still learning about different approaches, we don't know which approach is the better one. We can say that both would "work".

AZT, ddI, and nevirapine was a combination studied a few years ago, in a trial called INCAS. In those who took all three meds faithfully, the regimen works very well, meaning that the viral load has a very high chance of getting to below detection on the ultrasensitive assays we now rely on. Both ddI and nevirapine can be taken just once a day, and AZT is a capsule that can be taken twice a day, so there is a low "pill burden" with this triple. About the only issue is that AZT tends to cause a bit of nausea in some people especially early on, and this often is lessened when it is taken with food. However ddI MUST be taken on an empty stomach. (There is a new 200 mg tablet of ddI which just became available in the US - the dose would be just two tablets a day.) If you had any nausea on the AZT, and took it with food, you would need to separate it from ddI because of this food issue, which means taking meds three times a day. Hopefully this isn't a big deal... Nevirapine can be either with or without food - it is very flexible.

DDI with HU (shorthand for hydroxyurea) is still considered more experimental even though it has been studied for a few years. The HU turns ddI into a more potent drug, and in studies where just this combination is given, a fair number (perhaps a third or more at your viral load level) will get to a viral load below detectable. Some will not, as it is probably less potent. However, there is research to suggest the possibility that HU targets the immunological function in a way that is not done with the standard antivirals. This might allow a less potent regimen to still be successful in the long term. Indeed, some are studying this type of approach with the hope that by only partially suppressing HIV in the presence of HU containing regimens, we can allow the immune system to still "see" HIV and learn how to control it -- thus, some have called ddI plus hydrea plus the immune system a triple combination approach. However we still have less data to guide us about the long term results with this approach - more information is expected later this year and hopefully we will better understand where this regimen fits into the options list.

Both can work. Both are pretty easy. Both leave you future options. Why not have the advisors talk with each other in your presence to see which approach sounds more attractive to you??

Good luck. CC